3. Discussion
According to our experience and previous reports, the laparoscopic approach to cholecystectomy may be useful 6. Pneumoperitoneum may increase the preload on the heart and cause vital changes in LVAD patients 8. However, in this case, no intraoperative change due to pneumoperitoneum was observed. In the present study, we performed pneumoperitoneum at 10 mmHg. However, previous reports suggest that a pneumoperitoneum at 10–15 mmHg is also acceptable (Table 1) 6 9-23.
There are currently nine case reports and seven case series in the literature, including 32 cases that described LC (Table 1). Of the 42 total cases (including the presented case), only one case (2.4%) converted to open surgery. Nearly half of the patients (40.5%) underwent scheduled elective surgery. This trend seems to be particularly strong since 2015. We speculate that this change is partly related to increased awareness of the acute cholecystitis guidelines24. i.e., the use of alternative methods such as gallbladder drainage rather than emergency surgery in the case of organ failure. However, the rate of PTGBD was not stated in many of the previous reports; therefore, the overall rate is unknown. The safety and efficacy of PTGBD have been confirmed by many case-control studies in patients with cholecystitis. PTGBD is recommended as a standard drainage method for patients with acute cholecystitis at high surgical risk24. In this case, the following factors contributed to our success: 1) the acute cholecystitis was treated with PTGBD to reduce inflammation before the scheduled surgery, 2) time was given before the scheduled surgery to consider warfarin antagonism, and 3) the surgery was performed in a calm circulatory state. In our case, the operation was completed safely, with lower blood loss compared to the blood loss in previous reports. Although our institution is not a heart transplant hospital, LVAD transplantation is performed in the Department of Cardiovascular Surgery at Tottori University Hospital. Patients with LVADs are admitted to our hospital. As the number of patients with LVADs is increasing worldwide, more cases of acute abdominal problems in patients after LVAD transplantation will be encountered. The use of PTGBD to reduce the cholecystitis before performing the LC is beneficial.
In conclusion, we described the case of a patient with end-stage heart failure and an implanted LVAD who was diagnosed with acute cholecystitis. The patient was successfully and safely treated with PTGBD followed by elective LC. In patients with LVADs who develop acute cholecystitis, the use of early PTGBD to eliminate inflammation in the biliary tract is useful. Awaiting surgery prevents fatal complications, such as perioperative bleeding and biliary tract injury.